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SURGICAL TREATMENT FOR SURGICAL TREATMENT FOR COLORECTAL CANCERCOLORECTAL CANCER
PROF. PANKAJ G. JANI, ASSOCIATE PROFESSOR, DEPARTMENT OF SURGERY, UNIVERSITY OF NAIROBI
COLORECTAL CANCER(CR)COLORECTAL CANCER(CR)MANAGEMENT IS BY A MULTIDISCIPLINARY TEAM
l C.R. SURGEONS
l ONCOLOGISTS
l RADIOTHERAPISTS
l DIAGNOSTIC RADIOLOGISTS
l NURSE SPECIALISTS
l HISTOPATHOLOGISTS
COLORECTAL CANCERCOLORECTAL CANCER
l SURGERY REMAINS THE MAIN STAY OF TREATMENT, EVEN IN METASTATIC DISEASE
PATHOLOGY PATHOLOGY
lMOST COMMON & CLINICALLY SIGNIFICANT CANCER OF THE BOWEL
l COMMONEST CAUSEE OF CANCER RELATED MORBIDITY & MORTALITY IN THE WEST {>35000 NEW CASES / YR (UK)}
DISTRIBUTION OF COLON CADISTRIBUTION OF COLON CA
l RIGHT COLON 20%
l TRANSVERSE COLON 10%
l LEFT COLON 5%
l RECTOSIGMOID 55%
l OTHER SITES 10%
RECTAL CANCERRECTAL CANCER
GOALS OF THERAPY FOR GOALS OF THERAPY FOR RECTAL CARCINOMARECTAL CARCINOMA
l DECREASE LOCAL RECURRANCE
l OPTIMISE Q.O.L. ®AVOID COLOSTOMY
ANATOMY OF RECTUMANATOMY OF RECTUM
l CHANGED FROM TRADIOTIONAL 22 CMS FROM ANAL VERGE TO 15 CMS
l ABOVE THAT IS NOW ALL COLON
CA. RECTUM (ESP. LOWER CA. RECTUM (ESP. LOWER TUMORS)TUMORS)
l SHOULD BE DIAGNOSED EARLY (DRE)
l SHOULD GIVE GOOD RESULTS WITH EARLY THERAPY
SYMPTOMSSYMPTOMS
l RECTAL BLEEDING
LOWER RECT.
l TENESMUS
l ALT. OF BOWEL HABITS
UPPER.
l ANY G.I. SxS (dyspepsia)
SURGICAL CHALLANGESSURGICAL CHALLANGES
l I - STAGING
l II - USE OF CH/RT
l III - SURGICAL TECHNIQUE
STAGING STAGING
lMODIFIED DUKES
lTNM
DUKES STAGING SYSTEM DUKES STAGING SYSTEM FOR COLORECTAL CANCERFOR COLORECTAL CANCER
Dukes Dukes stagestage
DefinitionDefinition Approximate five year Approximate five year cumulative survival (%)cumulative survival (%)
AA Tumour confined to the mucosaTumour confined to the mucosa 9595
B1B1 Tumour invading the muscularis propria but Tumour invading the muscularis propria but not the serosanot the serosa
9090
B2B2 Tumour invading the serosa but no lymph node Tumour invading the serosa but no lymph node involvementinvolvement
6060
C1C1 Tumours with metastasis to regional lymph Tumours with metastasis to regional lymph nodesnodes
4040
C2C2 Tumours with metastasis to regional and/or Tumours with metastasis to regional and/or apical lymph node involvementapical lymph node involvement
1010
DD Distant metastases presentDistant metastases present <10<10
STAGINGSTAGING
DECIDES –TRANS ANAL LOCAL EXCISION « APR
.
- NEOADJUVANT CH/RT
TRADITIONAL STAGINGTRADITIONAL STAGING
l DIGITAL RECTAL EXAMINATION
l CT SCANS
NEWER STAGING NEWER STAGING METHODSMETHODS
l DRE
l ERUS – NODES
l CT
RECENT ADVANCESRECENT ADVANCES
l DRE
l ERUS
lMRI
STAGINGSTAGING
DRE FOR ADVANCED TUMORS
STAGINGSTAGING
l ERUS
l T STAGE ACCURACY 60 – 90%
l N STAGE ACCURACY 60 – 90%
lMRI
l T STAGE ACCURACY 60 – 90%
l N STAGE 40 --- 80%
l ( NODES > 5mm)
RECENT ADVANCES ERUSRECENT ADVANCES ERUS
l ERUS
------ BEST FOR NODAL STATUS
( OPERATOR DEPENDANT)
CHALLANGECHALLANGE
l PICK UP < NODES < 5mm (33%OF ALL <NODES)
l PICK UP MICRO METS
l USE OF CH/RT
STAGING MRISTAGING MRI
l HIGH RESOLUTION THIN SLICE (<1mm)
l DEPTH OF EXTRAMURAL SPREAD ACCURATELY IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION MARGIN)
l TRADITIONAL
- PROXIMAL
- DISTAL
l RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS IMP.
RESECTION MARGINS IMPORTANT
RECENT ADVANCE MRIRECENT ADVANCE MRI
INDICATORS OF MALIGNANT NODAL INVOLVEMENT
L. NODES
IRREGULAR BORDER
MIXED SIGNAL INTENSITY OF NODE
RECENT ADVANCE MRIRECENT ADVANCE MRI
l DETECTS EXTRAMURAL VENOUS INVASION (EMVI)
l POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT
II USE OF CH/RT II USE OF CH/RT (NEOADJUVANT/ADJUVANT)(NEOADJUVANT/ADJUVANT)
l PTS WITH POOR HISTOLOGY
l PTS WITH EXTRA MURAL SPREAD (MRI)
l PTS WITH INVOLVED NODES (ERUS)
l PTS WITH EMVI (MRI)
III SURGICAL TECHNIQUE III SURGICAL TECHNIQUE TRADITIONALTRADITIONAL
l PROCTECTOMY PERFORMED
-- In the DARK
-- Using BLUNT Dissection
-- Without attention to ANATOMIC Detail
RESULTED in
-- Bloody operation
-- Increased -- Autonomic Nerve injury
-- APR rates
-- Local Rec.
SURGERY SURGERY -- TRADITIONALTRADITIONAL
l ANT. RESECTION – UPPER ⅓ RECTAL CA
l LOW ANT.RESCETION- MID ⅓ RECTAL CA
l A.P.R. - LOWER ⅓ RECTAL CA
l ANY TUMOR 10cms FROM ANAL VERGE-APR
..
Dangerous Practices
RECTAL CA. RECENT ADVANCES
RECTAL CARCINOMA RECTAL CARCINOMA RECENT ADVANCESRECENT ADVANCES
l >100 YEARS SINCE MILES DESCRIBED
ABDOMINO-PERINEAL-RESECTION
l >25 YEARS SINCE HEALD DESCRIBED
TOTAL MESORECTAL EXCISION
III SURGICAL TECHNIQUEIII SURGICAL TECHNIQUERECENT ADV.RECENT ADV.
TOTAL MESORECTAL EXISION
( EXICISION OF FASCIA ENVELOPING THE FAT PAD AROUND THE RECTUM.)
SAUSAGE APPEARANCE
SURGERY SURGERY –– RECENT RECENT ADVANCESADVANCES
l LOW-ANT RESECTION – UPTO 6cms FROM ANAL VERGE
l APR – ONLY IF SPHINCTOR FUNCTION COMPROMISED
RECTAL CANCER RECTAL CANCER ––RECENT ADVANCESRECENT ADVANCES
l CAREFUL ASSESSMENT OF SxS
¯
EARLY DIGNOSIS WITH
¯
ACCURATE STAGING
¯
CH/RT - FOR SELECTED PTS
- PROCTOSCOPY- SIGMOIDOSCOPY
- DRE- ERUS- MRI
RECTAL CANCER RECTAL CANCER ––RECENT ADVANCESRECENT ADVANCES
l CH/RT - FOR SELECTED PTS
¯SURGERY
¯
RESTAGE
(With Histology)
¯
ADTUVANT CH/RT
TRANSANAL RESECTION- (TEM)
- LOW ANT RESECTION- APR
CHEMOTHERAPYCHEMOTHERAPY
l INJ KYTRIL 3mg Ksh 2,250/-
l INJ DEXAMETHAZONE 8mg Ksh 385/-
l INJ FLUOUROURACIL 5500mg Ksh 12,053/-
l INJ OXALIPLATIN 200mg Ksh 187,600/-
l INJ LEUCOVORIN 100mg Ksh 1,809/-
l INJ AVASTIN 400mg Ksh 213,806/-Kshs417903/-
RADIOTHERAPYRADIOTHERAPY
l EUROPEAN APPROACH
l (25G/5CYCLES)
l SHORT COURSE – LOW DOSE – IMMEDIATE SURGERY
l NO CHANGE IN PATH STAGING
l LOWER COST
l BETTER COMPLIANCE
l DOSE EQUIVALENT TO 30-33G
l EXPECT 66% REDUCTION IN LOCAL RECURRENCE
l AMERICAN APPROACH
l (45 – 54G/28 CYCLES)
l PROLONGED COURSE –HIGH DOSE – DELAYED SURGERY
l BETTER SURGICAL TOLERANCE
l MORE TUMOR REGRESSION
l EXPECT >80% REDUCTION IN LOCAL RECURRENCE
A GOOD SET OF REGULAR BOWEL MOVEMENTS IS BETTER THAN ANY AMOUNT OF BRAINS
COLON CANCERCOLON CANCER
SOME DIFFERENCES FROM RECTAL CANCER
DIAGNOSISDIAGNOSIS
l COLONOSCOPY
l SIGI. --- FLEXIBLE ( LIMITED COLONOSCOPY)
--- RIGID
DOUBLE CONTRAST BA. ENEMA
COLORECTAL CANCER COLORECTAL CANCER DIAGNOSIS DIAGNOSIS –– MISSED LOCALLYMISSED LOCALLY
l PATIENTTS WITH UNDIAGNOSED DYSPEPSIA
l PATIENTS WITH UNDIAGNOSED IRON DEFECIENCY ANAEMIC
l PATIENTS WITH POSITIVE FAECAL OCCULT BLOOD
ELECTIVE SURGERY FOR ELECTIVE SURGERY FOR COLON CANCERCOLON CANCER
l 70% OF COLON CA PRESENT ELECTIVELY
PRE-OP. THOROUGH STAGING IS NOT AS ACCURATE AS FOR RECTAL CANCER
TUMOR AND NODE STAGED POST OP.
TNM STAGING SYSTEM FOR TNM STAGING SYSTEM FOR COLORECTAL CANCERCOLORECTAL CANCER
TUMOUR (T)TUMOUR (T) DEFINITIONDEFINITION
TT Primary tumour cannot be assessedPrimary tumour cannot be assessed
T0T0 No evidence of primary tumourNo evidence of primary tumour
TisTis Carcinoma in situ: intraepithelial or invasion into the lamina Carcinoma in situ: intraepithelial or invasion into the lamina propria with no extention through muscularis mucosae into propria with no extention through muscularis mucosae into submucosasubmucosa
T1T1 Tumour invades into submucosa, but not the muscularis propria Tumour invades into submucosa, but not the muscularis propria
T2T2 Tumour invades into but not through the muscularis propriaTumour invades into but not through the muscularis propria
T3T3 Tumour invades through bowel wall into subserosa or nonTumour invades through bowel wall into subserosa or non--peritonealized pericolic/perirectal tissuesperitonealized pericolic/perirectal tissues
T4T4 Tumour invades other organs and structures and/or perforates Tumour invades other organs and structures and/or perforates visceral peritoneumvisceral peritoneum
TNM STAGING SYSTEM FOR TNM STAGING SYSTEM FOR COLORECTAL CANCERCOLORECTAL CANCER
NODES (N)NODES (N) DEFINATIONDEFINATION
NxNx Regional lymph nodes cannot be assessedRegional lymph nodes cannot be assessed
N0N0 No regional lymph node metastasesNo regional lymph node metastases
N1N1 11--3 regional lymph node(s)3 regional lymph node(s)
N2N2 4 or more regional lymph nodes4 or more regional lymph nodes
METASTASES (M)METASTASES (M) DEFINATIONDEFINATION
MxMx Metastatic disease cannot be assessedMetastatic disease cannot be assessed
M0M0 No evidence of metastatic diseaseNo evidence of metastatic disease
M1M1 Distant metastases presentDistant metastases present
SPREAD SPREAD –– COLON CANCERCOLON CANCER
l LOCAL EXTENSION
l VASCULAR INVASION
l TRANSCOELOMIC SPREAD
lMUSCULARIS MUCOSA – FEW LYMPHATICS
lMUSCULARIS PROPRIA – RICH IN LYMPHATICS
LYMPHATIC SPREADLYMPHATIC SPREAD
l EPICOLIC NODES
l PERICOLIC NODES
l INTERMEDIATE NODES
l PRINCIPLE NODES
ARTERIES OF LARGE INTESTINESARTERIES OF LARGE INTESTINES
ADVANCED DISEASEADVANCED DISEASE
l RADIOLOGICAL EVALUATION ( CT )
l HISTOPATHOLOGICAL STAGING (T4)
l NEOVADJUVENT CHEMORADIOTHERAPY®DOWNSIZE ® SURGERY
HISTOLOGYHISTOLOGYl TUBULAR DIFFERENTIATION
DETERMINES GRADE:-
l 20% WELL DIFFERENTIATED
l 20% POORLY DIFFERENTIATED
l 60% MODERATELY DIFFERENTIATED
Lack of Guidelines and Standards
Inadequate supervision
Common Problems Facing Surgery in Africa
RT.HEMICOLECTOMYRT.HEMICOLECTOMY
EXTENDED RT. EXTENDED RT. HEMICOLECTOMY HEMICOLECTOMY
TRANSVERSE COLON CANCERTRANSVERSE COLON CANCER
LT. HEMICOLECTOMYLT. HEMICOLECTOMY
SIGMOID COLECTOMYSIGMOID COLECTOMY
RECENT ADVANCERECENT ADVANCE
l LAPAROSCOPIC COLON RESECTIONS (16 Cms RESEC. To 11Cms RESEC.)
RECENT ADVANCERECENT ADVANCE
l RESECTION OF HEPATIC/PULMONARY METASTASIS
OUR SCENARIOOUR SCENARIO
l LATE PRESENTATION
l ADVANCED TUMORS
l ANATOMICAL DISTORTION
l LACK OF NEOADJUVENTS
l SURGERY MORE DIFFICULT
l RESULTS POORER
THANK YOUTHANK YOU
